Patient Care

For Physicians

Guidelines for Administration of Gadolinium Based Contrast Agents (GBCAs) for MRI (November, 2007)

Reducing Risk of NSF - Overview

• Identify high risk patients
• Is the MR necessary (alternative algorithms)
• Is the GBCA necessary?
• If GBCA is used:
     - Use lowest possible dose
     - Avoid repeat examinations in short period of time
     - Consider other GBCAs

Identify High Risk Patients
    Identify patients at the time of scheduling

• Dialysis
     - When contrast-enhanced (CE) MRI is ordered through HIS, a message asks if patient is on dialysis
     - If “yes”, the exam cannot be scheduled without a nephrology consult
  
• CKD (Chronic Kidney Disease)
     - When CE MRI is ordered through HIS, a message asks if the patient has Acute Kidney Injury (Acute Renal Failure) or if eGFR is less than 30 ml/min/1.73m2 (40 for severe liver disease)
     - If “yes”, the exam cannot be scheduled without a nephrology (hepatology) consult 
     - For inpatients, eGFR must be obtained within 72 hrs of MRI exam (24 hrs for liver patients)

    Idenitfy Outpatients    

• Dialysis
     - Scheduler asks every patient (or whomever is ordering exam) if on dialysis
     - If “yes”, told that exam will not be scheduled until nephrologist caring for patient (in consultation with radiologist) has agreed and has arranged for appropriate dialysis
  
• CKD (Chronic Kidney Disease)
     - Scheduler asks patient whether they have kidney disease, problems with their kidneys (including solitary kidney, renal transplant, or renal tumor), hypertension, liver disease, or diabetes.
     - If “yes” or >60 years old, they are informed that their referring physician must provide a recent eGFR obtained within the prior 6 weeks (within 24 hrs prior to exam for liver disease) before the exam can be scheduled
     - If the patient’s eGFR is less than 30 ml/min/1.73m2, (40 for severe liver disease) the exam will not be scheduled without documented consultation with a radiologist

    Identify Inpatients at the time of the exam

• Questions concerning kidney disease, diabetes, hypertension, liver disease, and dialysis have been added to the patient safety questionnaire, which is filled out by the patient at the time of the exam
• The MR technologist/nurse/nurses aid checks the answers prior to preparing the patient for the exam
• If the patient indicates that they may have a problem and this was not identified at scheduling, the attending radiologist or his/her designate is consulted concerning the appropriate course of action
     - May require “stat” Cr/eGFR, which requires vein puncture and takes 1-2 hrs

Note: When the EZ-Chem device becomes available, all patients who are scheduled for administration of GBCA will undergo point-of–service testing to determine the eGFR. This test can be administered by any trained personnel. The calculated eGFR will be entered on the patient safety questionnaire, and the entire form will be scanned into Fuji Synapse.

• If the eGFR is > 30 ml/min/1.73m2, (40 for severe liver disease), administration of GBCA may proceed
• If the eGFR is < 30 ml/min/1.73m2, (40 for severe liver disease), and after consultation with the referring physician, the decision is made to administer GBCA:
     - Informed consent, which explains risk of NSF is obtained by the radiologist (Note: informed consent is not required for administration of GBCA to patients who are not at increased risk for NSF). Download Consent form (pdf)
     - Explicit order for IV contrast is signed by a radiologist (not referring physician) that states amount and specific type of agent to be administered for a specific MR exam

During the MRI Exam:

• CE MRI exams use a dose of ­<0.1mmol/kg Gd-chelate
     - Every patient is weighed prior to exam
• Higher doses may be used in certain exams (eg. peripheral run-offs), but only after the risks-benefits have been carefully weighed by the referring physician, patient, and supervising radiologist and eGFR>30 is confirmed

After the MRI Exam:

• Patients at risk for NSF should be closely observed after GBCA exposure and instructed to contact healthcare professional regarding potential symptoms such as:
     - skin burning, itching, reddened/darkened patches and/or inflammation,
     - hardening, and/or tightening
     - yellow raised spot of the sclera
     - joint stiffness
     - limited peripheral movement
     - deep hip/rib pain
     - muscle weakness